Total Parenteral Nutrition Standardization and Electronic Ordering to Reduce Errors: a Quality Improvement Initiative

Abstract

Introduction: Total parenteral nutrition (TPN) provides vital intravenous nutrition for patients who cannot tolerate enteral nutrition but is susceptible to medical errors due to its formulation, ordering, and administrative complexities. At Johns Hopkins All Children's Hospital, 22% of TPN orders required clarification of errors and averaged 10 minutes per order for error correction by pharmacists. Quality improvement methodology improved patient safety by standardizing TPN formulations and incorporating TPN ordering processes into the electronic medical record.

Methods: A multidisciplinary group of providers developed standardized TPN solutions for neonatal and pediatric patients. Inclusion, exclusion, and discontinuation criteria were defined. The primary outcome measure was reducing TPN ordering error rate, and secondary outcomes were improving TPN ordering and processing time along with reducing blood draws. Through multiple plan-do-study-act cycles, we standardized TPN solutions, incorporated them in the electronic medical record, monitored blood draws, and evaluated resource efficiency. Data were analyzed using chi-square tests of independence and t tests for 2 independent samples.

Results: The TPN ordering error rate significantly decreased from baseline of 22% to 3.2% over the final quarter of the study period, χ² (1, N = 2,467) = 89.13, P < 0.001. Order processing time fell from 10 to 5 minutes by project end. The average number of blood draws decreased significantly from 6.2 (SD = 3.12) blood draws to 4.3 (SD = 2.13) in the last quarter of the study, t (506) = 5.97, P < 0.001.

Conclusions: Standardizing TPN and transitioning to electronic ordering effectively and significantly reduced ordering errors and processing time. It also substantially improved resource efficiency by reducing the number of blood draws.

Fig. 1.

Run-chart of errors following implementation of standardized TPN. Errors in TPN ordering were tracked against standardized TPN utilization. Baseline data were collected between November 2014 and January 2015. Despite consistent use of standardized TPN with electronic ordering in eligible patients, the error rate remained low from the beginning of this project’s implementation.

Fig. 2.

Utilization of standardized TPN for combined neonates and pediatric patients. Utilization of the standardized TPN composition was tracked for patients on TPN and meeting eligibility criteria. A, Illustrates breakdown of usage for standardized and customized TPN solutions for all patients receiving TPN during the study period, broken down by month. B, Illustrates utilization with the proportion of orders for standardized TPN given to eligible patients by quarter for comparison to baseline.